Electronic Submission of Claims

for Traditional Products

WHAT IS ELECTRONIC SUBMISSION OF CLAIMS?

This is a form of claim submission done by hospitals,
doctors, prescription drug venders and other providers. The applicable
provider will electronically transfer an employee or dependent’s claim
to the administrator instead of mailing a paper claim. The last few
years have seen a significant increase in this type of claim submission.

WHAT IS REQUIRED FOR REIMBURSEMENT OF THESE CHARGES WHEN THE PROVIDER OF SERVICE IS A PRESCRIPTION DRUG VENDER?

The Employer must have coverage for their Prescription Drug Card Plan under the stop loss policy.

For an aggregate claim, an audit will usually be performed
on site. A review of the prescription drug bills will be done as part of
the audit. The actual bills from the vender must be available to audit.
This includes electronically submitted vender bills.

For a specific claim, the prescription drug bills for the
individual involved need to be submitted with documentation indicating
when the vender was paid for each drug. Documentation of the actual
bills, whether submitted by the vender to the administrator via paper
claim or electronic claim, must be submitted. In the case of
electronically submitted bills, a printout of the vender’s charges needs
to be submitted for the specific claim individual. An administrator
paid claims report of prescription drug charges is not sufficient
documentation as this is not a copy of the prescription drug charges.

WHAT IS REQUIRED FOR REIMBURSMENT OF THESE CHARGES WHEN THE PROVIDER OF SERVICE IS NOT A PRESCRIPTION DRUG VENDER?

A copy of the electronically submitted claim. This would
include an electronic bill that can be printed in a UB-92/HCFA format or
a printed copy of the electronically submitted claim data.